Statistics

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Health is one of the main components of wellbeing in developed societies&#46; World Health Organization defined health broadly about 60 years ago&#44; but life expectancy and mortality have typically been used to define a population&#39;s state of health&#46; As medical and public health advances have led to cures and better treatment of diseases&#44; and thereby delayed mortality&#44; it is logical that those who measure health outcomes will begin to assess the population&#39;s health not just on the basis of extending life expectancy&#44; but also in terms of improving the quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a> Thus&#44; the concept of health-related quality of life &#40;HRQOL&#41; and its determinants has evolved over the last 40 years&#46; Some authors have described HRQOL as the outcome of the interaction of variables across four levels&#58; biological and psychological factors&#44; symptoms&#44; functioning &#40;psychologically and socially&#41;&#44; and general health perception&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">2</span></a> HRQOL has been defined as the individual&#39;s perception of their position in life in the context of the culture and value systems they live in&#44; and in relation to their goals&#44; expectations&#44; standards&#44; and concerns&#46; It is a broad ranging concept affected in a complex way by the person&#39;s physical health&#44; psychological state&#44; level of independence&#44; social relationships&#44; and their relationship to salient features of their environment&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Measuring HRQOL can help summarise the patient&#39;s experience of illness&#44; and therefore characterise the social burden of chronic disease&#46; Assessing HRQOL and its distribution across populations will help monitor our progress in achieving population health objectives&#44; therefore contributing to reduce health inequalities between individuals&#44; communities&#44; and regions in our society through greater improvements in more disadvantaged communities&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">4</span></a> Understanding relationships among the HRQOL components will allow for designing more effective public health interventions&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">HRQOL determinants have been broadly studied&#46; Numerous studies have demonstrated the association between physical&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">6</span></a> psychological&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">7</span></a> and social determinants and changes in HRQOL perception&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">8&#44;9</span></a> Individuals with better functioning capacity&#44; social support&#44;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">10&#44;11</span></a> socioeconomic status&#44;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">12&#44;13</span></a> and psychological condition<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">14</span></a> display superior perception of HRQOL&#46; Self-perceived HRQOL has also been related to lifestyle factors&#44; such as being physically active&#59;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">15&#44;16</span></a> in contrast&#44; it has been found to be inversely correlated with negative conditions&#44; such as obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">17</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In the Spanish population&#44; HRQOL has been described in detail&#44; and differences in HRQOL by regions have been reported&#44;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">18&#44;19</span></a> although the extent of the influence of personal and environmental factors on HRQOL perception is unclear&#46; Understanding these relationships can be of great interest in planning interventions to improve health outcomes and elucidating the reasons for certain outcomes&#46; This study sought to identify the burden of several determinants on HRQOL&#44; measured via the EQ-5D-5L&#44; in the Spanish population&#44; and to assess the potential HRQOL heterogeneity among the different Spanish regions&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Design</span><p id="par0025" class="elsevierStylePara elsevierViewall">Cross-sectional study using data from the 2011-2012 National Health Survey &#40;NHS&#41;&#44; whose methodology is published and described in detail&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Population</span><p id="par0030" class="elsevierStylePara elsevierViewall">The NHS was performed in 2&#44;000 of the 35&#44;960 sections of the 2011 Municipality Population Census&#44; including 12 households per section area&#46; Three-phase sampling&#44; stratified by population size&#44; was performed &#40;census section&#44; homes&#44; and people in the home suitable for survey participation&#41;&#44; to achieve a representative sample at a region level&#46; The sample comprised one survey for minors and one for individuals aged &#62;15 years&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables</span><p id="par0035" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Dependent variables&#58; the selected dependent variable was perceived HRQOL&#46; The NHS assessed quality of life using the EQ-5D-5L questionnaire&#44; a generic survey validated for the Spanish population&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">21</span></a> The first part consists of 5 questions concerning the following dimensions&#58; mobility&#44; self-care&#44; performance of usual life activities&#44; pain&#47;discomfort&#44; and anxiety&#47;depression&#46; Each dimension is measured on a 5-point scale&#44; and a single weighted score &#8212;the utility index&#8212; is obtained from these five questions&#46; This score lies on a scale in which full health has a value of 1 and death has a value of 0&#44; although negative values are allowed&#46; The algorithm suggested for Spain<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">22</span></a> was used to obtain this index&#46; The second part consists of a visual analogue scale &#40;EQ-VAS&#41; ranging from 0 &#40;poorest condition&#41; to 100 &#40;best possible health condition&#41;&#46; Both the utility index and the EQ-VAS score were used as dependent variables&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Independent variables&#58; demographic data included age&#44; sex&#44; and the region where individuals resided&#46; The social variables included place of birth &#40;national&#47;foreign&#41;&#44; social class &#40;which includes six categories based on occupation&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">23</span></a> and social support measured using the Spanish version of the Dukes-Unk11 scale&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">24</span></a></p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">Three questions from the NHS were chosen to measure the capacity to perform daily activities&#58; &#8220;Do you suffer from a chronic or long-lasting disease or problem&#63;&#8221; &#40;yes&#47;no&#41;&#59; &#8220;during the last two weeks&#44; have any health issues forced you to stay in bed for more than half a day&#63;&#8221; &#40;yes&#47;no&#41;&#59; &#8220;in the last six months&#44; how much have you been limited due to a health problem when performing normal daily activities&#63;&#8221; &#40;severely limited&#47;mildly limited&#47;not limited at all&#41;&#46; The first question allowed assessment of the diagnosed chronic disease&#44; the second determined short-term severe limitation in performing daily activities&#44; and the third determined chronic limitation &#40;with two stages&#44; mild and severe&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Mental health was appraised using Goldberg&#39;s General Health Questionnaire &#40;GHQ-12&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">25</span></a> This tool detects probable psychiatric morbidity&#46; Total scores range from 0 &#40;best mental health&#41; to 12 &#40;poorest mental health&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Variables related to lifestyle included smoking habit &#40;active smoker&#44; occasional smoker&#44; ex-smoker&#44; or non-smoker&#41;&#44; alcohol consumption &#40;measured in grams per week&#41;&#44; body mass index &#40;&#91;BMI&#93;&#59; underweight&#44; normal weight&#44; overweight&#44; or obese&#41;&#44; and physical activity &#40;never&#44; occasionally&#44; several times per month&#44; or several times per week&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">The distributions of the variables were analysed&#46; Confidence intervals &#40;CI&#41; were calculated using bootstrap techniques&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Tobit regression models with upper censoring at 1&#46;0 &#40;or 100 for the EQ-VAS&#41; were used to study the influence of the variables on the expressed HRQOL&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">26</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The marginal effects of the different variables for the unconditional expected score of the HRQOL&#44; measured at the mean values of the other covariates&#44; were reported&#46; These marginal effects are interpreted as the change in the HRQOL score associated with the variable in question&#44; adjusted for the other covariates&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">27</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Separate models were built for utility and EQ-VAS measures&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Covariates were included in the model in five groups&#44; seeking to embrace the described multidimensional concept of HRQOL<span class="elsevierStyleSup">3</span>&#58; demographic characteristics&#44; physical status and level of independence &#40;chronic conditions and limitations in daily activities&#41;&#44; social support&#44; mental health status&#44; and lifestyle&#46; Specification errors and the goodness of fit of the models were examined using Akaike information criteria &#40;AIC&#41;&#44; Bayesian information criteria &#40;BIC&#41;&#44; and Cox-Snell R<span class="elsevierStyleSup">2</span>&#46; The lower the AIC and BIC or the higher the R<span class="elsevierStyleSup">2</span> scores&#44; the better the model fitted the data&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Residuals were used to study differences in HRQOL by regions&#44; which other studies suggested existed&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">19</span></a> Their intraclass correlation coefficient &#40;ICC&#41; was calculated to estimate how much of the residuals&#8217; variability was related to regional aggregation&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">28</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The best model was chosen based on its goodness of fit&#44; its framing within the previously published literature&#44; and the principle of parsimony&#46; STATA 12&#174; software was used for the analysis&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0100" class="elsevierStylePara elsevierViewall">Of the 21&#44;007 subjects aged &#62;15 years who answered the questionnaire concerning HRQOL&#44; 20&#44;979 did so in a way in which utility scores could be obtained&#46; Of these&#44; 62&#46;4&#37; &#40;95&#37;CI&#58; 61&#46;8&#37;&#8211;63&#46;2&#37;&#41; expressed a utility score of 1&#46; Of the entire sample&#44; 20&#44;821 subjects reported their health condition using the EQ-VAS&#44; 54&#46;2&#37; of whom &#40;95&#37;CI&#58; 53&#46;5&#37;&#8211;54&#46;9&#37;&#41; reported a score of &#8805;80&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the distributions of variables and the number of subjects from whom they were obtained&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows how the incorporation of additional covariates improved the fit of the models to the HRQOL data&#46; Demographic variables contributed significantly to explaining the variability in responses&#44; and so did disease-related variables&#46; Social variables were strongly correlated with HRQOL perception but did not improve the model&#44; and even reduced the R<span class="elsevierStyleSup">2</span>&#46; The variable accounting for mental health improved the model adjustment&#46; Variables related to lifestyle &#40;physical activity and BMI&#41; were also associated with HRQOL&#44; but did not improve the global capacity of the model&#46; Alcohol consumption and smoking habit were not included in model 5&#44; since their coefficients were negligible and worsened the model&#39;s fit&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">In <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#44; the best models are shown in detail&#46; Female sex was associated with a reduction in HRQOL measured in utilities &#40;&#8722;0&#46;017 points&#41;&#46; Each 10-year increase in age was associated with a decrease of 0&#46;020 points in utilities&#44; and 2&#46;420 points on the EQ-VAS&#46; Age squared coefficients were tested in the model&#44; but did not achieve a better fit&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Experiencing a chronic condition&#44; severe limitations for the preceding 2 weeks&#44; and chronic limitation for the preceding 6 months were also associated with a perception of poorer quality of life&#44; with severe limitations experienced for the preceding 6 months exerting the greatest effect&#46; These limitations caused average reductions of 0&#46;373 points in utilities and 17&#46;867 points on the EQ-VAS&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Disadvantaged social classes were associated with poorer perceived HRQOL&#44; measured using both the utility index and the EQ-VAS&#44; and a gradient was observed indicating that the lower the social class&#44; the poorer the HRQOL reported&#46; Differences of 0&#46;016 points in utilities were observed between social classes I and VI&#46; Similarly&#44; every two standard deviations &#40;15&#46;0 points&#41; increase in the social support score was related to a decrease of 0&#46;003 points in utilities and 1&#46;397 points on the EQ-VAS&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The association between Goldberg&#39;s test score and HRQOL was negative&#46; Every two standard deviations &#40;5&#46;52 points&#41; increase in Goldberg&#39;s score was associated with a decrease of 0&#46;041 points in utilities and 8&#46;234 points on the EQ-VAS&#46; The relationship between BMI and HRQOL was only evident when comparing obesity with normal weight &#40;&#8722;0&#46;012 points in utilities and &#8722;1&#46;911 on the EQ-VAS&#41;&#46; Physical activity was related with improved HRQOL&#46; Individuals who engaged in physical activity several times per week had increases of 0&#46;026 points in utilities and 3&#46;975 points on the EQ-VAS compared to those not performing any physical activity&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Models for subjects older and younger than 50 years of age were built&#44; but no significant differences were observed between their coefficients&#59; therefore&#44; only general models are presented&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> shows the distribution of the gross residuals for the utility values in each region &#40;the non-explained variability&#41;&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a> shows the residuals for the EQ-VAS model&#46; No significant differences were found between different regions once the adjusted predicted values were subtracted from the expressed values&#46; The ICC was 0&#46;004 for the utility residuals and 0&#46;020 for the EQ-VAS score residuals&#44; which implies that 0&#46;4&#37; and 2&#37;&#44; respectively&#44; of the variability of the residuals was due to the effect of regional aggregation&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0145" class="elsevierStylePara elsevierViewall">HRQOL perception in the Spanish population varied slightly depending on the measure used &#40;utility index or EQ-VAS&#41;&#46; HRQOL was strongly related to age&#44; mental health&#44; and the presence of limitations in daily life activities&#44; particularly in the case of long-term limitations&#46; Social class was positively correlated with HRQOL&#44; as were certain health behaviours such as being physically active or maintaining a normal weight&#46; These results are not surprising as these factors have been found to be related to HRQOL in other studies&#59;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">11&#44;14&#44;29</span></a> however&#44; the way in which emotions&#44; mental distress&#44; social problems&#44; and physical illness are perceived&#44; experienced&#44; and expressed are dependent on culture and environment&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">30</span></a> Therefore&#44; we found it valuable to study the distribution and relative weight of determinants of HRQOL in the Spanish population in a comprehensive way&#46; Additionally&#44; the findings suggest that previously reported differences in HRQOL by regions were due to differences in the population characteristics rather than contextual effects&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Sociodemographic characteristics&#44; especially ageing&#44; were strongly related to HRQOL&#44; although health expectations have been hypothesised to be readjusted throughout life&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">31</span></a> Contrary to other studies&#44;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">32</span></a> we did not find differences in the factors that impact HRQOL between people under or over 50 years of age&#44; suggesting that ageing worsened perceived HRQOL&#44; but did not influence its determinants&#46; Previously observed differences in HRQOL<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">33</span></a> by sex were only noted when utility indexes were used&#44; and could be influenced by social determinants and lifestyle&#44; particularly in older individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">34</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Variables related to social class<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">12&#44;13</span></a> and social support<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">10&#44;11</span></a> have been shown to greatly influence differences in HRQOL&#46; It has been reported that more generous welfare regimes experience lesser socioeconomic inequalities in their quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">9</span></a> Hence the relative importance of social class and how one&#39;s perception of social support is associated with perceived HRQOL&#44; which could be studied in future research in the context of our welfare system&#39;s strength&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The influence of factors related to chronic disease in explaining HRQOL is well known&#44;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">35</span></a> but this study emphasizes the role of perceived limitations to shape the relationship between disease and HRQOL&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">6</span></a> and the findings suggest that interventions addressing limitations can provide significant health benefits&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">36</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Mental health condition has been found to have a strong association with reported HRQOL&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">14</span></a> The negative effect of a poor mental condition on the individual&#39;s HRQOL has been previously reported in the Spanish population&#44; suggesting the need for global policies aimed at reducing this burden&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">7</span></a> These results highlight the fact that mental health status can be as relevant as age and chronic limitations in explaining differences in reported HRQOL in the Spanish population&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Regarding the role of health-related behaviours&#44; alcohol and tobacco consumption did not showed a clear association with reported HRQOL&#46; The relationship between alcohol consumption and HRQOL has been difficult to model&#44;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">37</span></a> and smoking has been related to a worse perception of HRQOL&#44;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">38</span></a> but it is possible that people with poorer health are recommended to cease these habits&#59; therefore&#44; expected associations are spurious or do not occur&#46; Better HRQOL was observed in those who referred any physical activity in their leisure time as opposed to those with no physical activity&#44; after adjusting for other determinants of HRQOL&#44; which is relevant because moderate increase of physical activity has been shown to produce improvements in HRQOL&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">39</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Obesity has been described as a factor associated with higher morbidity and poorer HRQOL&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">17</span></a> In this study&#44; overweight subjects showed a slightly higher HRQOL than normal weight subjects&#44; measured by utility score but not when using the VAS scale&#46; Robust differences in HRQOL were only found between obese and normal-weight subjects&#44; as other studies reported&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">40</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Research on health-related contextual effects has been performed&#44; maybe spurred by an increasing interest in macro-social influences on the individual&#39;s health status&#46; The research has mainly focused on the relationship between spatially concentrated deprivation and health&#44; but empirical findings are controversial and depend on the studied aggregation level&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">41</span></a> Significant differences in expressed HRQOL by regions has been described in Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">19</span></a> as well as in other countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">11&#44;42&#44;43</span></a> Differences in the effect of context on HRQOL have also been reported in the Spanish population&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">29</span></a> In contrast to these works&#44; we studied a larger body of variables related to HRQOL&#44; such as social class and&#44; perhaps even more importantly&#44; perceived limitations&#44; which yielded negligible differences among regions&#46; This suggests that differences could mainly be due to compositional differences among region populations rather than contextual effects&#44; which could explain the differences in reported HRQOL&#46; As with other studies&#44; the relatively large size of the included administrative area can hinder the detection of any significant contextual effect related to HRQOL at those regional levels&#44;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">44</span></a> but these findings are relevant in the Spanish health setting since services are designed at that specific level&#46; Reported differences in HRQOL could lead to change normative values of HRQOL tests&#44;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">42</span></a> or to strengthen public health policies in disadvantaged regions <a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">43</span></a>&#46; In Spain&#44; interventions to improve HRQOL should be tailored for different target populations according to age&#44; impairment&#44; mental health status&#44; or social class&#44; but not different regions&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">This study was subject to design limitations&#46; First&#44; its cross-sectional design limits the possibility to establish causal relationships&#46; Therefore&#44; the absence of an association between tobacco or alcohol consumption and HRQOL could be a consequence of disease or the actions of health agents&#46; Another limitation is that some data were self-reported&#44; and a certain bias of indulgence might be present&#46; Additionally&#44; tariffs for EQ-5D-5L were estimated from the cross-walk index from the Spanish tariffs&#44; an approach with several limitations&#44; like placing an artificial floor effect on the values of the 5L&#44; when the EQ-5D-3L is used for comparison&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">22</span></a> On the other hand&#44; there is a current debate on whether censoring regression methods are appropriate to make estimations over the censored part of the variables&#44; as previous anchor measures for the utilities and VAS should not be used&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">45</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Regarding the strengths of the study&#44; the survey methodology poses the best approximation of the Spanish population&#39;s health at present&#44; and the methodology used in the analysis fits the particularity of the sampling method&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">This study has several implications&#46; It must be noted that when assessing the effect of a disease on HRQOL in the Spanish population&#44; its impact is better explained by the impairment or emotional burden rather than the presence of the disease itself&#46; Hence&#44; interventions to improve HRQOL must act on the components that result in limitations in daily activities and the agents that affect mental health&#44; a valid approach for any age range&#46; Promoting physical activity&#44; especially for those who do not engage in leisure physical activity&#44; and interventions aimed at preventing obesity could also be helpful for the maintenance of good HRQOL perception&#46; On the other hand&#44; HRQOL can be a useful measure to identify health inequalities among individuals and communities&#44; and this study highlights the importance of taking social class into consideration when public health interventions are being planned&#46; However&#44; in order to study differences in HRQOL by regions&#44; identifying compositional effects is necessary before attributing these differences to contextual covariates&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">In summary&#44; and given the relevance of HRQOL for a population&#39;s health&#44; the findings of this study can allow for identifying subgroups which should be specifically targeted&#44; like the elderly or those belonging to the least favoured classes&#44; and to set priorities for effective public health interventions&#44; especially promoting physical activity or healthy ageing&#44; early interventions to limit impairment or chronic conditions&#44; and mental health strategies&#46;<elsevierMultimedia ident="tb0005"></elsevierMultimedia></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Editor in charge</span><p id="par0215" class="elsevierStylePara elsevierViewall">Maria-Victoria Zunzunegui&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Transparency declaration</span><p id="par0220" class="elsevierStylePara elsevierViewall">The corresponding author on behalf of the other authors guarantee the accuracy&#44; transparency and honesty of the data and information contained in the study&#44; that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Authorship contributions</span><p id="par0225" class="elsevierStylePara elsevierViewall">J&#46; Mart&#237;n-Fern&#225;ndez&#44; I&#46; del Cura-Gonz&#225;lez and A&#46; Sarria-Santamera conceived the idea and designed the study&#46; J&#46; Mart&#237;n-Fern&#225;ndez and I&#46; del Cura-Gonz&#225;lez got the cleaned and annotated database&#46; J&#46; Mart&#237;n-Fern&#225;ndez&#44; G&#46; Ariza-Cardiel&#44; E&#46; Polentinos-Castro and T&#46; Sanz-Cuesta developed the statistical analysis and discussed the preliminary results&#46; J&#46; Mart&#237;n-Fern&#225;ndez&#44; G&#46; Ariza-Cardiel&#44; E&#46; Polentinos-Castro&#44; T&#46; Sanz-Cuesta&#44; A&#46; Sarria-Santamera and I&#46; del Cura-Gonz&#225;lez studied the meaning of the results and their health policy implications&#46; All authors have discussed and approved the submitted manuscript&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Funding</span><p id="par0230" class="elsevierStylePara elsevierViewall">This manuscript has been translated and edited with the support of ISCIII and FEDER Funds&#44; Grant Number RD12&#47;0001&#47;0012&#46; Publication charges have been supported by ISCIII&#44; grant Number 1300648&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0235" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess the burden of several determinants on health-related quality of life &#40;HRQOL&#41; and to study its heterogeneity among the different Spanish regions&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cross-sectional study&#46; Data were obtained from the Spanish National Health Survey &#40;2012&#41;&#44; and HRQOL was measured using the EQ-5D-5L questionnaire &#40;utility and visual analogue scale &#8211;VAS&#8211; scores&#41;&#46; Demographic variables&#44; physical health condition&#44; social variables&#44; mental health status&#44; and lifestyle were also analysed&#46; Tobit regression models were employed to study the relationships between expressed HRQOL and personal characteristics&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 20&#44;979 surveys were obtained&#46; Of them&#44; 62&#46;4&#37; expressed a utility score of 1&#44; corresponding to perfect health &#40;95&#37;CI&#58; 61&#46;8&#37;&#8211;63&#46;2&#37;&#41;&#44; and 54&#46;2&#37; showed VAS scores &#8805;80 &#40;95&#37;CI&#58; 53&#46;5&#37;&#8211;54&#46;9&#37;&#41;&#46; HRQOL was mainly described as a function of age&#44; chronic limitation in daily activities&#44; and mental health status&#46; Belonging to a higher-class strata and physical activity were related to better self-perceived HRQOL&#46; Ageing worsened perceived HRQOL&#44; but did not influence its determinants&#44; and differences in HRQOL by regions were also not significant after model adjustment&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">HRQOL perception in the Spanish population varied slightly depending on the measure used &#40;utilities index or VAS&#41;&#46; Age&#44; chronic limitations in daily life&#44; and mental health status best explained the variability in perception&#44; and no meaningful differences in HRQOL perception among regions were found after adjustment&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Method"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar la carga de ciertos determinantes de la calidad de vida relacionada con la salud &#40;CVRS&#41; y su heterogeneidad entre diferentes regiones espa&#241;olas&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio transversal&#46; Utilizando datos de la Encuesta Nacional de Salud &#40;2012&#41;&#44; se midi&#243; la CVRS con el cuestionario EQ5D-5L &#40;utilidad y escala visual anal&#243;gica &#91;EVA&#93;&#41;&#46; Se analizaron variables demogr&#225;ficas&#44; estado de salud&#44; variables sociales&#44; salud mental y estilos de vida&#44; utilizando modelos Tobit&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 20&#46;979 encuestas&#46; El 62&#44;4&#37; de los sujetos expres&#243; una utilidad de 1&#44; perfecta salud &#40;intervalo de confianza del 95&#37; &#91;IC95&#37;&#93;&#58; 61&#44;8&#37; -63&#44;2&#37;&#41;&#44; y el 54&#44;2&#37; mostr&#243; puntuaciones en la EVA &#8805;80 &#40;IC95&#37;&#58; 53&#44;5&#37;-54&#44;9&#37;&#41;&#46; La CVRS se vio modificada fundamentalmente por la edad&#44; la limitaci&#243;n cr&#243;nica en las actividades diarias y el estado de salud mental&#46; La clase social alta y la actividad f&#237;sica aparec&#237;an relacionadas con una mejor CVRS&#46; La edad empeor&#243; la percepci&#243;n de la CVRS&#44; pero no se asoci&#243; con un cambio en la influencia de sus determinantes&#46; Despu&#233;s de ajustar los modelos&#44; no hab&#237;a diferencias en la CVRS en las diferentes regiones&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La percepci&#243;n de la CVRS en la poblaci&#243;n espa&#241;ola vari&#243; dependiendo de la medida utilizada &#40;utilidades o EVA&#41;&#46; La edad&#44; las limitaciones cr&#243;nicas en la vida diaria y el estado de salud mental explicaban fundamentalmente las diferencias en la CVRS&#44; y las diferencias entre regiones se explicaron principalmente por diferentes caracter&#237;sticas poblacionales&#46;</p></span>"
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            "titulo" => "M&#233;todos"
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            "identificador" => "abst0035"
            "titulo" => "Resultados"
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            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
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          0 => array:4 [
            "apendice" => "<p id="par0250" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0085"
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      ]
    ]
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            "Alto" => 1078
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of the residuals for the predicted utilities in the different regions in Spain&#46;</p>"
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        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Distribution of the residuals for the Visual Analogue Scale scores in the different regions in Spain&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Quantitative variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Median &#40;interquartile range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age &#40;years&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">51&#46;6 &#40;51&#46;3&#8211;51&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#46;0 &#40;36&#46;0&#8211;66&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#44;007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Social support &#40;Duke-UNC 11&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47&#46;8 &#40;47&#46;7&#8211;47&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#46;0 &#40;44&#46;0&#8211;55&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&#44;997&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mental health &#40;Goldberg 12&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;6 &#40;1&#46;6&#8211;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;0 &#40;0&#46;0&#8211;2&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#44;695&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Weekly alcohol consumption &#40;g&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">547&#46;3 &#40;536&#46;2&#8211;558&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;0 &#40;0&#46;0&#8211;857&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#44;810&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Utilities &#40;EuroQol-5D-5L&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;89 &#40;0&#46;89&#8211;0&#46;90&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;00 &#40;0&#46;89&#8211;1&#46;00&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#44;979&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">EuroQol-VAS &#40;EuroQol-5D-5L&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&#46;7 &#40;75&#46;5&#8211;75&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&#46;0 &#40;65&#46;0&#8211;90&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#44;821&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Qualitative variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Percentage &#40;95&#37;CI&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sex</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#44;007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Woman&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&#46;1 &#40;53&#46;4&#8211;54&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#44;365&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Men&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">45&#46;9 &#40;45&#46;2- 46&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#44;642&nbsp;\t\t\t\t\t\t\n